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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T, UJ SK 06 7 c'ag <br /> OWNER/OPERATOR X <br /> &-e— All /� ^dO CHECK If BILLING ADDRESS <br /> FACILITY NAME q the SP�f // t / l <br /> SITE ADDRESS <br /> L/ Street Number I Direction F Stre�etlName CI ZI Cod¢ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t APN# LAND USE APPLICATION# <br /> 00 aha—PY <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> e o r CHECK If BILLING ADDRESS <br /> BUSINESS NAME "'T <br /> /T PH E# Ems' <br /> The S o _ C/4l rr . aloes 3 <br /> HOME Or MAILING ADDRESSe / (AX# ) <br /> J O( -! C/ /l�/T G <br /> CITY t Y ni' STATE zip (9(3 7 <br /> ! s✓ <br /> BILLING ACKNO LEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/Or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to be Rplarmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,S�T/A�T�and FEDERALalaWS.APPLICANT'S SIGNATUR.E::: `�� DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> if APPLICANT IS not the BILLING PARTY /hoof Of auth0rization to Sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time It Is provided t0 me Or <br /> my representative. PA <br /> TYPE OF SERVICE REQUESTED: CAnw <br /> �CJV <br /> COMMENTS: �` P.1 <br /> G AMR 1 VV <br /> t')e0 ��°-� <br /> 0 <br /> N FNVVVV N C <br /> l <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> AsSIGNEDTO: EMPLOYEE#: DATE:✓� � -/ <br /> Date Service Completed (if air eady completed): SERVICE CODE PIE: 1,210 <br /> Fee Amount — -- S} Amount Paid 6 2S SO Payment Date 3 -e2 v - 1-7 <br /> PaymentTypeG,,�S Ir\ Invoice# Check# Received By: <br /> v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />